Health inspection·December 18, 2024

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of Resident1 ' s Minimum data set (MDS- a federally mandated assessment tool) dated 8/28/24 indicated a BIMS ( brief interview for mental status) score of 0 out of 15 which meant Resident 1 ' s cognition was severely impaired. A record review of Resident 1 ' s History and Physical record dated 5/23/24 indicated Resident 1 does not have the capacity to understand and make her own decisions. A record review of Resident 1 ' s Physician ' s order sheet dated 11/24 did not have an order for any type of physical restraint. A review of Resident 1 ' s medical record did not indicate any consent from Resident 1 ' s family for a restraint use. A record review of Resident 1 ' s care plan did not indicate a physical restraint care plan. There was no documented evidence to indicate the physician was notified before applying the sheet across Resident 1. A phone interview on 11/15/24 at 3:42 P.M., with LN 2 was conducted. LN 2 stated CNA 2 called him and showed underneath Resident 1 ' s blanket. LN 2 stated a flat sheet wedge and rolled up (strap size) across Resident 1 ' s shoulders and chest area with both sides of the sheets wedged under the mattress were observed. LN 2 asked CNA 2 to call the Director of Nursing (DON). A phone interview on 11/15/24 at 3:42 P.M., with LN 2 was conducted. LN 2 stated CNA 2 called him and showed the flat sheet underneath Resident 1 ' s blanket. LN 2 stated a flat sheet wedge and rolled up (strap size) across Resident 1 ' s shoulders and chest area with both sides of the sheets wedged under the mattress were observed. LN 2 asked CNA 2 to call the Director of Nursing (DON). A phone interview on 11/15/24 at 4 P.M., with the DON was conducted. The DON stated on 10/29/24 at around 8:00 A.M., LN 2 called and notified her and asked her to assess Resident 1. The DON stated she took a picture of Resident 1 while she was in bed with a flat sheet over her chest area. The DON stated a restraint was applied to Resident 1. The DON stated it was not permitted in the facility to have any resident on restraints unless necessary. The DON stated a Physician ' s order and a consent from the responsible party was required before a restraint was applied to Resident 1. The DON stated Resident 1 did not have a physician order for restraint. The DON further stated it was important to not have any resident on any type of restraint chemical or physical to prevent injury or health decline. The DON stated she spoke to LN 1 who was working that evening and stated he intentionally applied the flat sheet to keep Resident 1 from pulling her foley catheter. A phone interview on 11/18/24 at 1:06 P.M., with CNA 2 was conducted. CNA 2 stated on 10/29/24 at 6:30 A.M. when she came in, she saw Resident 1 lying in bed covered with a blanket. CNA 2 stated an hour after (7:30 A.M.), CNA 2 went back to Resident 1 ' s room to provide care. CNA 2 stated she uncovered Resident 1 ' s blanket and saw the folded flat sheet tucked on both sides under Resident 1 ' s mattress. CNA 2 took off one side of the folded white sheet underneath the mattress, then called LN 2 and the DON. A phone interview on 11/22/24 at 9:36 A.M., with the DON was conducted. The DON stated, We have included the facility policy on Abuse Prevention that included misuse of restraints. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555134 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555134 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Miguel Covenant Village 325 Kempton St. Spring Valley, CA 91977 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the Nursing Home Resident Rights indicated Your Right to be Free from Restraints As a resident in a nursing home, you have the right to be free from physical and chemical restraints . A review of the facility policy titled Abuse Prevention dated 10/22 .misuse of restraints- Chemical or physical control of a resident beyond the physician ' s orders or not in accordance with the resident ' s plan of care .includes any physical or mechanical device, material, or equipment attached or adjacent to the resident ' s body that the resident cannot remove easily that restricts freedom of movement or normal access to ones ' body . Event ID: Facility ID: 555134 If continuation sheet Page 3 of 3